Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Hi Dr Sher, is it possible to transfer mosaic embryos where there is more than one chromosome with an error, ie a complex aneuploid/mosaic embryo (if this terminology is correct)
It is possible, but in my opinion, not advisable.
Geoff Sher
Hi Dr Sher, you mentioned that PGS accuracy is around 75% and does not test reliably for mosaicism. Given older women are more prone to getting mosaic embryos would you still recommend PGS for older women – as PGS would only end up disposing of potentially usable embryos. If the PGS results show an embryo as aneuploid, is it possible that this embryo is in fact mosaic?
I am not sure I agree that mosaicism is necessarily more prevalent in the embryos of older women. There is to my knowledge no DEFINITIVE evidence to that effect.
Geoff Sher
Hi doctor,
I’m in process of IVF now and have a question. I have 10 folicules on eaxh of the ovaries and E2 level after 8 days of stimulation was 2100. I got my last dosage of stimulation today and monday at 3 am is my trigger shot time. I got 10000IU of chorimon. However, admission of it is in muscle which is dificult at home. For this reason doctor recomended Ovidrel 250. I read your past comments and articles and i doubt i should get ovidrel. What do you recommend?
I concur. If Ovidrel is used it should be 500mcg, in my opinion.
Geoff Sher
Could my glucose level of 112 effect embryo implantation?
In my opinion, highly unlikely.
Geoff Sher
Hello Dr. Sher,
You wrote in you blog: “Embryo abnormalities account for 70%-80% of IVF failure, while implantation problems (including immunologic factors), only account for 20%-30%”. How would this ratio change if we check an embryo with PGD before transfer and confirm that it is euploid?
I’m 41 y.o. We have had 5 IVF cycles so far, in the last 2 cycles we had short antagonist protocol (Gonal-F/Cetrotide) and got 4 (2 x 2) euploid embryos (PGD/24 aCGH, blastocyst). 3 of them failed to implant after frozen embryo transfer and 1 was cryobanked. Now we plan our 6th cycle. We will carefully check once again for implantation problems, but we cannot understand if we should change the protocol as it’s been proven to yield euploid embrios? In the last cycle we had day 2 LH 7.3 mUI/ml, FSH 9.7 mIU/ml, Estradiol 218 pmol/l, day 6 LH 2.4 mIU/ml, Estradiol 3866 pmol/l. Before last FET we had intravenous gamma globulin, after FET: dexamethasone and fraxiparine.
Thanks in advance,
Irina
If your protocol is producing euploid embryos consistently, then the problem almost certainly is likely to be implantation dysfunction and you will need to be fully evaluated for this. Special emphasis needs to be placed on immunologic issues and remember, these tests are best done by a Reproductive Immunology Reference Laboratory such as Reproductive Immunology Associates in Van Nuys, CA. Also, please note that NK cell blood concentration is irrelevant. It is NK cell activity as measured by the K-562 target cell blood test and/or uterine cytokine analysis that matters.
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The Fundamental Requirements For Achieving Optimal IVF Success
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for IVF
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
?800-780-7437
Geoff Sher
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Hello Dr. Sher,
Thank you for a quick reply!
We maybe overcomplicating, but does it look totally impossible that we had suboptimal IVF cycle and got embryos with fatal defects which nevertheless successfully passed aCGH? If that was true we would probably consider long protocol in our next IVF cycle, because it would enable better control over hormone levels. However we faced life-endangering OHSS in our first IVF cycle with long protocol and that makes it hard choice for us…
So we have a dilemma now: take a risk and try long protocol again (but only because we have unjustified concerns about aCGH reliability) or trust aCGH and concentrate on potential implantation disfunctions. And the latter would be a natural choice if we have not tried already intravenous gamma globulin + dexamethasone (NK activation) and fraxiparine treatment (APA) with our aCGH-approved embryos, and all in vain.
Thank you again,
Irina